Table.
Current Recommendations for NAFLD Screening
| AASLD, 20187 | EASL, 20169 | NICE, 20168 | |
|---|---|---|---|
| Screening Recommendations | No recommendations are made for screening, even in high-risk groups (obesity, type 2 diabetes), due to uncertainties in diagnostic testing, long-term management, and cost-effectiveness. Maintain a high degree of suspicion for NAFLD or NASH in patients with type 2 diabetes. |
Patients with obesity or metabolic syndrome should be routinely screened with liver enzymes and/or ultrasound. High-risk patients (age >50 years, type 2 diabetes, or metabolic syndrome) should be assessed for more advanced disease. Patients with persistently elevated liver enzymes should be screened for NAFLD. | No recommendations are made for screening due to lack of evidence. Providers should be made aware that patients with type 2 diabetes or metabolic syndrome are more likely to have NAFLD. If NAFLD is already diagnosed, patients should be offered the ELF test to screen for fibrosis every 3 years. |
| Diagnosis or Workup | Rule out other common causes of chronic liver disease. If workup is negative and other comorbidities such as features of metabolic syndrome, hypothyroidism, polycystic ovarian syndrome, or sleep apnea are present, further investigation should take place. | Ultrasound is the first-line test for diagnosis. If ultrasound is unavailable or not feasible, serum biomarkers or steatosis scores should be used. Proton-MRI is generally not recommended for diagnosis due to expense. |
Rule out other common liver diseases. Liver enzymes should not be used to rule out NAFLD. Ultrasound is not recommended due to lack of cost-effectiveness. |
| Noninvasive Tests to Diagnose NASH and Stage Fibrosis | NFS or FIB-4 clinical prediction rules can be used to identify patients at higher risk of advanced fibrosis. VCTE or MRE may also be used to identify fibrosis. | Biomarkers, fibrosis prediction scores, or VCTE are acceptable methods of identifying patients at low risk of advanced fibrosis. | The ELF test should be offered to everyone with NAFLD to assess for advanced fibrosis. If the initial testing was negative, repeat every 3 years. |
| Liver Biopsy Recommendations | Liver biopsy should be considered in patients who have been identified as being at higher risk for fibrosis with noninvasive measures or in patients with metabolic syndrome in whom advanced disease is suspected. | If advanced fibrosis or cirrhosis has been identified, patients should undergo liver biopsy for confirmation. | No recommendations are given. |
| Treatment | Lifestyle changes are the primary recommendation, with an ideal targeted weight loss of 7%-10% of body weight. Pharmacotherapy should only be given to patients with biopsy-proven NASH. Vitamin E can be given to nondiabetic patients with biopsy-proven NASH. Pioglitazone can be considered in patients with or without type 2 diabetes. |
Lifestyle changes are the primary recommendation, with an ideal targeted weight loss of 7%-10% of body weight. Pharmacotherapy should be reserved for cases of biopsy-proven NASH or for patients at risk of advancement. Pioglitazone or vitamin E can be used for NASH, but if enzymes do not normalize within 6 months, these therapies should be stopped. |
Patients should be referred to specialists if advanced fibrosis is identified. Vitamin E or pioglitazone can be used in patients with advanced fibrosis, although comorbidities should be considered. Repeat the ELF test 2 years after starting medications. If the score rises, consider stopping medication. |
AASLD, American Association for the Study of Liver Diseases; EASL, European Association for the Study of the Liver; ELF, Enhanced Liver Fibrosis; FIB-4, Fibrosis-4; MRE, magnetic resonance elastography; MRI, magnetic resonance imaging; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; NFS, NAFLD Fibrosis Score; NICE, National Institute for Health and Care Excellence; VCTE, vibration-controlled transient elastography.